Recent data estimate that one of every 10 to 20 (5%-10%) hospitalized patients experience a healthcare-associated infection (HAI) each year. HAI are associated with almost 100,000 deaths annually in the United States. Many studies show that HAI increase hospital length of stay, and
morbidity and mortality rates. Strategies have been proposed to prevent HAI. In Appendix 10, some of the important guidelines for prevention of HAI are summarized. More details are available in the Web sites listed at the conclusion of this chapter. Guidelines cannot always account for individual variation among patients and are not intended to supplant physician judgment with respect to individual patients or special clinical situations.
Key Points
Life-Threatening Infections
Fever is the most frequent systemic manifestation that raises the suspicion of infection.
Ideally, appropriate cultures should be obtained before initiation of antibiotics in patients with suspected infection.
Selection of appropriate empiric antimicrobial therapy depends on the suspected pathogen(s) and site of infection, Gram stain results of available specimens from the suspected site, assessment for antimicrobial resistance, and comorbid conditions.
When bacterial meningitis is suspected clinically, antimicrobial therapy should be instituted immediately, without waiting for the results of lumbar puncture.
The most common organism resulting in community-acquired, life-threatening pneumonia is Streptococcus pneumoniae.
Resistant gram-negative organisms and Staphylococcus aureus are frequent causes of pneumonia in hospitalized patients or in those who require mechanical ventilation.
Bactericidal antimicrobial therapy, high concentrations of the antimicrobial agent, the resistance pattern of the microorganism, and long-term therapy are the cornerstones of therapy for infective endocarditis.
Suspicion of intra-abdominal infection requires the prompt involvement of a surgeon.
Necrotizing soft tissue infection requires prompt surgical debridement in addition to broad- spectrum antimicrobial therapy.
In the absence of a specific source and pending culture results, broad-spectrum antimicrobial therapy is indicated in the immunocompromised or neutropenic patient with fever.
Fungal infection should be considered in the presence of predisposing factors, such as malignancy, neutropenia, broad-spectrum antimicrobial therapy, parenteral nutrition, severe burns, or organ transplantation, or if central venous vascular catheters are in place.
Suggested Readings
1. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.
Am J Respir Crit Care Med. 2005;171:388-416.
2. Avecillas JF, Mazzone P, Arroliga AC. A rational approach to the evaluation and treatment of the infected patient in the intensive care unit. Clin Chest Med. 2003;24:645-669.
3. Calandra T, Cohen J, International Sepsis Forum Definitions of Infection in the Intensive Care Unit Consensus Conference. The International Sepsis Forum Consensus Conference on Definitions of Infection in the Intensive Care Unit. Crit Care Med. 2005;33:1538-1548.
4. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: International guidelines
for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008;36:296-327.
5. Guerrant RL, Van Gilder T, Steiner TS, et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32:331-351.
6. Leone M, Bourgoin A, Cambon S, et al. Empirical antimicrobial therapy of septic shock patients: Adequacy and impact on the outcomes. Crit Care Med. 2003;31:462-467.
7. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community- acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27-S72.
8. Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for management of intravascular catheter- related infections. Clin Infect Dis. 2001;32:1249-1272.
9. O’Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008;36:1330–1349.
10. Pappas PG, Rex JH, Sobel JD, et al. Guidelines for treatment of candidiasis. Clin Infect Dis.
2004;38:161-189.
11. Solomkin JS, Mazuski JE, Baron EJ, et al. Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. Clin Infect Dis. 2003;37:997-1005.
12. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267-1284.
13. Yokoe DS, Mermel LA, Anderson DJ, et al. A compendium of strategies to prevent healthcare- associated infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29 Suppl 1:S12-S21.
Web Sites
1. Centers for Disease Control. http://www.cdc.gov. This Web site contains regularly updated guidelines for management and prevention of specific infections.
2. Infectious Diseases Society of America. http://www.idsociety.org. This Web site contains regularly updated guidelines for management and prevention of specific infections.
Chapter 12